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TRAM Flap Physio

Declined or Delayed Reconstruction

TRAM Flap and Physio.

A flap of the woman’s own tissue is used to reconstruct a natural feeling and looking breast. A flap is skin, fat, muscle or any combination of these tissues that is transferred from one part of the woman’s body to another for reconstructive purposes. Common donor sites are the lower abdominal wall and back and less common but useful sites are the buttocks and upper inner thighs.

TRAM image 1. Free TRAM Flaps. TRAM image 2. Pedicled Flap transferred while still attached to the abdominal muscle.


Ref: “A Woman’s Decision” free publication via www.synovismicro.com

Free TRAM flap: The fat, skin, blood vessels, and muscle are cut from the wall of the lower abdomen and moved up to the chest to reconstruct the breast. The surgeon reattaches the blood vessels of the flap to blood vessels in the chest using microsurgery. In the “muscle-sparing” free TRAM flap the surgeon uses a smaller part of the rectus abdominis muscle for the flap, instead of a large portion of the muscle, lowering the risk of losing abdominal muscle strength.

A pedicled (or attached) TRAM flap: Now the fat, skin, blood vessels, and muscle from the lower abdominal wall are moved under the skin up to the mastectomy site to rebuild the breast. The blood vessels (the artery and vein are the pedicle) of the flap are left attached to their original blood supply in your abdomen. Pedicled TRAM flaps use a large portion of the rectus abdominis muscle and are known as “muscle-transfer” flaps. Recovery is longer and the risk of losing abdominal muscle strength is higher.

TRAM Outcomes
Tram flaps look and feel natural and soften and drop like the other breast over the next several months. Over time the reconstructed breast also ages like the other breast. The other breast may also get a surgical lift to achieve symmetry. While the patient does have a new and lengthy abdominal scar the “tummy tuck” is generally appreciated.

TRAM physio guidelines: The transverse rectus abdominis muscle stabilizes the abdominal oblique muscles and so resecting it results in abdominal wall and core weakness. The ability of TRAM patients to recruit the abdominal muscles is permanently compromised. A history of low back problems contraindicates a TRAM as it contributes to less spinal support and stability.

For 4-8 weeks post-op these patients are unable to stand upright and will benefit from learning spinal precautions during activities of daily living (ADLs) e.g. rolling onto their side when transferring from supine to standing, using their hips and knees when lifting, driving and doing ADLs that involve forward flexion. Housework e.g. making beds, filling the dish washer, lifting food in and out of the low oven and vacuuming are particularly difficult to do. Spinal precautions will help TRAM patients do the ADSLs while also avoiding straining the surgical sites and their lower backs.

The abdominal wall becomes permanently numb due to nerve disruption when creating the tunnel, so observe skin precautions if using ice and hot packs.

Arm motion is limited and abduction is discouraged in the early weeks. Patients can begin gentle shoulder range of motion (ROM) 2-3 weeks post-operatively and begin abdominal exercises 2 months post-op. As with all major abdominal surgery, lifting and driving is avoided for 2 months and after that started carefully.

Because trunk flexion is permanently impaired, patients cannot do “100s” in Pilates, and are advised to rebuild core strength slowly and carefully, advancing from level one only if and when they can maintain the pelvis in a neutral position. Teaching and observing pelvic neutral is a key step in early breast cancer reconstruction rehab.

TRAM Image 3. Final TRAM scar and reconstructed and tattooed nipple-areola.


Contact Siobhan@theoreillycentre.ie with your comments and questions.

Sex Therapy After Cancer

Sex Therapy After Cancer
Breast cancer Rehab for Physiotherapists Course

This article “Sex therapy after cancer” by Relationships Ireland was approved for the course by Siobhan O’ Reilly Bracken MISCP MPA CLT MSc

Physiotherapists may refer patients to specialists such as Relationships Ireland for sex therapy after breast cancer.
Email: info@relationships.com
Ph: Relationships Ireland on 01 678 5256
Website: http://www.relationshipsireland.com/sex-therapy/sex-therapy-after-cancer/


Sex therapy after Cancer

Individuals diagnosed with cancer face many challenges during treatment and beyond. Side effects are common with most treatments and can vary from nausea and fatigue to problems with intimacy and sexuality. Many cancer patients experience sexual side effects which can be quite distressing for both the patient and their partner.

When faced with a cancer diagnosis and the challenges of treatment, it is not surprising that feelings of intimacy and sexual desire may decrease. Physical changes can have an effect on one’s feelings of attractiveness. Individuals with breast cancers or cancers of the head and neck often develop body image concerns which can result
in sexual side effects. Psychological issues can also arise due to a cancer diagnosis. The diagnosis itself may cause anxiety or depression and these conditions, or the medication used to treat them, can result in side effects that influence libido or sexual functioning.

Sexual Side Effects of Cancer Treatments
Various treatments for cancers can affect sexual functioning and one’s desire to be intimate.

Chemotherapy: Chemotherapy can affect libido for men and women because it can cause side effects such as diarrhoea, fatigue, mouth sores, and nausea, which make people feel unwell and uninterested in sex.

Radiation therapy: Depending on the organ being treated, radiation therapy can cause sexual and physical side effects that may reduce one’s interest in sex. For example, any radiation therapy affecting the gastrointestinal tract can lead to pain and stenosis (shortening) in structures such as the oesophagus, and/or diarrhoea. This can then have an effect on one’s libido.

Surgery: Even though surgeons try to prevent many nerves from being damaged during surgery to remove a tumour, sometimes this is not possible. Severed nerves can contribute to sexual issues. Following prostatectomy, men may experience erectile dysfunction or urinary incontinence which may stop them from wanting to be intimate with their partner. Women who have undergone an oophorectomy to remove the ovaries can experience a decrease in their libido because of the resulting decline in circulating oestrogen and testosterone levels. Having a mastectomy to treat breast cancer can cause women to develop an altered body image which can result in reduced interest in sex.

Hormone Therapy: Hormone therapy for the treatment of cancers can have many sexual side effects. For men these can include; erectile difficulties, altered body image, reduced self-confidence, decreased feelings of attractiveness, and painful ejaculations. For women, the side effects of hormone therapy can include; vaginal dryness, painful intercourse, loss of energy, decreased feelings of attractiveness, and difficulty achieving orgasm.

The Importance of Communicating and Connecting with Your Partner
Here are some tips to help you to improve communication between you and your partner so as to maintain or renew your sexual connection. However, if your problems persist, your concerns need to be addressed with your doctor.
• Openly discuss with your partner how you are feeling emotionally and what physical difficulties you are experiencing.
• Encourage your partner to talk about their concerns and needs too.
• Recognise that intimacy doesn’t just mean sexual intercourse. There are lots of ways to be intimate with your partner such as kissing, hugging or cuddling.
• Lubricants and moisturisers can be very effective for relieving vaginal dryness.
• If scars or surgery make you feel uncomfortable with your body then try wearing clothing or lingerie that makes you feel more relaxed, or you could try keeping the room dimly lit.
• Mix up your routine by trying different sexual positions, lighting candles, playing soft music, having sex in a place other than your bedroom, or experimenting with intimacy aids.
• To prevent fatigue, try having a nap or picking a time of the day when you have the most energy to engage in sexual activity.

Loss of sexual interest is a complicated problem but being and having an understanding and supportive partner is very helpful. Couples counselling or psychosexual therapy can be very beneficial for couples who are affected by cancer. If you would like to find out more or book an appointment with a certified Relationships Ireland counsellor, you can contact us here. A one hour Psyschosexual counselling session costs €85.00. Relationships Ireland operate a cancellation policy. For more details click here.

Please send your comments or questions to Siobhan@theoreillycentre.ie

Declined or Delayed Reconstruction

Declined or Delayed Reconstruction
Breast Cancer Rehabilitation For Physiotherapists

Updated October 2016. Written by Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT. Email questions and comments to Siobhan@theoreillycentre.ie
“Post mastectomy, conservative and surgical approaches”

Declined or Delayed Reconstruction


After a unilateral or bilateral mastectomy women today have several next steps to consider, including “to reconstruct or not to reconstruct” their breast or breasts. It’s both a personal and a medical decision.

As Physiotherapists we are an integral part of the oncology team and it is critical that we understand these options and the common associated rehabilitation challenges. There are three main approaches post mastectomy including:

• #1 The patient selects a conservative approach, to not have or delay reconstruction and is referred to a specialist for specially designed mastectomy bras, prostheses and swimwear.
• #2 The patient selects a surgical reconstruction and is referred to a breast surgeon for tissue expanders and implants
• #3 The patient selects an autologous reconstruction (using her own tissue) and is referred to a plastic surgeon for either a Latissimus dorsi flap, a Tram, Diep or SIEA flap, an IGAP or SGAP flap or a PAP or TUG flap.

A. The conservative (non-surgical) approach

For personal and/or medical reasons a patient may choose not to have or to delay surgical reconstruction surgery. She may choose to have professionally fitted bras with/without prostheses (or pads). Todays mastectomy bras are pretty, cosmetic and covered by medical insurance. The fitters are certified and they stock a wide range of mastectomy lingerie that looks great and is designed to help women feel a little better about the changes they have just undergone.


The certified fitter may also recommend padding or silicone prosthesis, which can be adjusted for size and personal preference and added into the bra pocket. There are certified fitters in many locations and women may locate their neighborhood service and Google the words “mastectomy bras and swimwear plus their location”. Mary Downey at www.almacare.ie/ volunteers her time to participate in our courses in Dublin. In her clinic, each woman is seen by appointment for a private one on one fitting. This is clearly a physically sensitive and emotional time for women especially soon after surgery and it’s important that they have a professional and supportive experience.

Rehab issues with Delayed Reconstruction.

The downside of the conservative approach is life without a breast, which may have different implications and meaning to each patient and their significant others. The patient should reach this conclusion after consideration of her options with her surgeon and oncologist, including the option to revisit her decision down the road.

The benefits of the non-surgical approach after mastectomy are:
• No risk of general postoperative side effects.
• No risk of donor site postoperative side effects.
• No new scars.
• A delayed decision allows for additional healing time.
• Others desire time to adjust before deciding.
• Significant co-morbidities e.g. circulatory problems or serious heart disease may take priority.
• Overall the patient has less rehabilitation needs and a shorter convalescence.


Specialist bra fitters, also stock beautiful swimwear that is designed to discreetly cover axillary clearance and mastectomy scars with pockets for pads and prostheses.


An ill-fitting swimsuit may act as a barrier whereas flattering swimwear may facilitate a woman’s decision to join a swim class, which can be restorative and fun.

See additional notes on “Swimming and Aqua Therapy

Swimming and Aqua-therapy

Swimming and Aqua-therapy
Breast Cancer Rehabilitation For Physiotherapists

Updated October 2016. Written by Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT. Email questions and comments to Siobhan@theoreillycentre.ie

“Why water based exercises warrant our special consideration when recovering from breast cancer”.

Swimming and Aqua-therapy after Breast Cancer

Patients at risk for secondary lymphedema help protect themselves by wearing Class 2 compression sleeves when exercising or flying. Class 2 compression sleeves exert between 23 – 32mmHg of pressure on the arm that has had lymph nodes removed and/or radiated as part of their breast cancer treatment..

In the pool at 50cm depth the hydrostatic pressure on the body is 35 mmHg. At 100cm depth the hydrostatic pressure on the body is 70mmHg. Therefore exercising in water has the dual benefit of exercise plus the water pressure acting like a compression sleeve which, prevents lymph from accumulating and facilitates the flow of lymph up and out of the arm.

So, besides being a total body exercise, swimming and aqua therapy helps reduce the risk of arm lymphedema.


Visit www.almacare.ie/ for post mastectomy swimwear ideas.

Water offers buoyancy or resistance to muscles as the arms and legs move into full range of motion in functional patterns. Patterns like the crawl, breaststroke and backstroke stretch the scarred and radiated skin. They open up the armpits, expand and pump the chest, tummy, hips, lymph nodes and lymph vessels. These patterns of movement are big, wonderful and symmetrical and so help recover the symmetrical strength of the shoulder blades, thoracic spine and chest muscles and correcting the “guarding and protective postures”.

Water-based aerobic and endurance training

Patients can also use water-based exercise for aerobic training (by speeding up in spurts or intervals) or for endurance training (by swimming slower at a constant speed and heart rate for longer).

Exercise is medicine – and the prescribed dose is > 35 minutes a day.

Our wellness experts all agree and recommend we all do more than 150 minutes per week of moderate exercise or more than 75 minutes per week of vigorous exercise to enjoy the mental and physical benefits of exercise – which includes the reduced risk of many common diseases.

Daily walking, aqua therapy, biking, cross trainer, tennis, basketball, skiing to name a few examples, helps breast cancer survivors achieve lean muscle mass and optimal body weight – which is co-related with less breast cancer recurrence.


Locate 10 pools near you!

Physios facilitate this by researching and recommending suitable local exercise groups to their patients. Research shows that the more fun and high quality a program is, the more likely a person is to experience positive results and the easier it becomes to commit to it longterm. For example with regard to water based exercise for recovery after breast cancer Physiotherapists in Ireland can use http://www.swimireland.ie/locate-a-pool/ to get a list of the 10 pools nearest to their patient. At an average cost of 7 euro per session this is an excellent all year round and weather independent option for all ages and income levels.

Please email siobhan@theoreillycentre.ie with your comments or questions.

Exercises for Shoulder Flexion

Exercises for Flexion

Breast Cancer Rehabilitation For Physiotherapists

Updated Oct 2016

By Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT

Email questions and comments to Siobhan@theoreillycentre.ie

The early exercises to reduce pain and recover shoulder flexion.

This short sequence of exercises were developed by Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT after studying the evidence for early mobility exercises and lymphedema prevention. See the Pre-Reading List for references. Please email Siobhan with comments or questions Siobhan@theoreillycentre.ie

Indications, Precautions and Contraindications

These exercises are indicated when patients:

  • Have early stage breast cancer and a non-capsular pattern of shoulder restriction (i.e. reduced flexion).
  • Have flexion limitation that is directly related to breast cancer surgical scars, cording and radiation fibrosis.
  • Have healthy bone i.e. patients do not have osteoporotic or metastatic bone lesions in the humerus, scapula, thoracic cage or vertebrae.
  • Do not have shoulder pathology that pre-existed breast cancer treatment or a capsular pattern.

Physiotherapists assess and prescribe who is appropriate for these exercises and who is not. When a breast cancer patient presents with precautions or contra-indications the Physiotherapist will modify accordingly (i.e. add and subtract exercises and the number of repetitions).

Building patient’s confidence to mobilize.

The Physiotherapist may teach these exercises first in the clinic so patients master the technique and experience immediate positive benefits. When patients experience the positive benefits of the exercises, their confidence builds. Only when patients feel safe and confident will they be motivated to follow through with the prescribed Daily Home Exercise Program (DHEP).

The benefits of early exercise include: (See pre-reading list for references)

  • Return of shoulder flexion.
  • Reduced pain, suffering, fear and anxiety.
  • Reduced guarding postures.
  • Prevents shortening of the scapular, SCM, pectorals, biceps, triceps, forearm, thumb and finger muscles and their pumping affect on the local circulation and lymphatic system.
  • Prevents adherent scars and adhesive capsulitis (which can inhibit the flow of the circulating, arteries, veins and lymph through the lymph vessels and nodes.
  • Reduces disuse muscle atrophy, general deconditioning and reduced aerobic endurance (aerobic exercise keeps the diaphragm effective in breathing and in pumping lymph fluid through the Long Thoracic Duct for re-entry into the venous system at the clavicles).
  • Exercise and movement mobilizes the skin of the chest, axilla and affected upper extremity so the superficial lymphatic system which is embedded in the skin.
  • All of the above combined accelerate recovery and reduce a patient’s risk of developing secondary lymphedema.

Written instructions for home exercise program (HEP).

It is best practice to print up and share these instructions with the appropriate patients so they can follow through correctly at home in between Physiotherapy sessions.

Monitoring outcome measures.

Before starting these exercises the Physiotherapist will record the patient’s pain and flexion. She will record the patient’s pain status, using the VAS scale of 0 – 10 (where 0 is = “I do not have any pain now” and up to 10 = “I have intense pain now”).  It is best to advise patients to move gently and to avoid overpressure and that pain above 3/10 is unacceptable and should be managed.  Patients should experience a decrease in pain and not an increase when doing their exercises.

The Physiotherapist measures shoulder flexion out of /180 degrees, using a goniometer. Finally she may also take a photograph of the patient in supine with the arm in flexion (with the patient’s written permission) for before and after comparisons. These outcomes measures are used when recording patient’s response to exercise and when reporting Physiotherapy outcomes to the oncology team.

TABLE 1. Monitoring changes in pain and shoulder flexion.






Equipment used:

  • An exercise mat,
  • A small pillow.
  • A 500gm Sissel Shaping Ball

Starting position A: Activating the posterior chain

Patient lies face-up on a mat with a small pillow under they head, squeezing a 500gm Sissel Shaping Ball between the bent knees, feet hip distance apart.

  1. Breathing: Patient places their hands on their lower ribs (over the diaphragm) inhales gently through the nose to a count of 4 seconds and exhales gently through the nose to a count of 8 seconds. Repeating up to 7 times.
  2. Breathing and Bridging: Patient inhales through your nose, pushing through the heels, lifting the hips up into a bridge, again with the Sissel ball between the knees then gently exhales and lets the hips down. Repeating up to 7 times.
  3. Breathing, bridging and flexing the arms: Patient inhales through the nose, lifting the hips up, squeezing the Sissel Ball and raising the arms up into flexion, then exhales and lets the hips and arms back down. Repeating up to 7 times.


Starting position B: Stretching the axilla (underarm) and chest.

  1. The patient rolls over and lies on their unaffected side, using the pillow to gently support the head.  First set up the lower body by asking the patient to lay the top foot over the bottom foot, the knee over knee and the hip over hip.
  2. Stretches the underarm out at right angles to the body
  3. Places the back of the top hand/the affected hand on their forehead (like a salute).
  4. Inhales gently rotating their upper body back so the shoulder blades lie on the mat. This will strain the axilla. When the patient feels tension just hold the stretch and breath in and out gently up to 7 breaths, breathing and stretching the axilla, without over-pressure. Patient then returns to side lying and back to position A.


Back in position A – the Physiotherapist re-assesses and records pain and shoulder flexion using the VAS scale and goniometer, and may re-photographs the new end point for the patient’s chart for recoding and reporting to the oncology team.

Home exercise prescription

Depending on the patient’s comfort level, the Physiotherapist will prescribe the number of repetitions for the Home Exercise Program (HEP) and print up the written instructions.

Comments and questions please to Siobhan@theoreillycentre.ie

Breast Oncology

This is an introduction to oncology for breast cancer physiotherapists developed by Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT as part of the course “Breast Cancer Rehabilitation for Physiotherapists ” – Updated Sept 20th 2016


Section 1. Oncology

What exactly is cancer?

“ Cancer is not a disease but a whole family of diseases. These diseases are linked at a fundamental biological level. They’re characterized by the proliferation of cells-occasionally cells that don’t know how to die, but certainly cells that don’t know how to stop dividing. That abnormal, uncontrollable growth of cells is a process that typically starts in a single cell and the cell multiplies over and over, and every generation produces a little evolutionary cycle such that you get more and more evolved cells. But although there’s a deep commonality between prostate cancer, breast cancer, leukemia, although they’re connected at the cellular level, every cancer has a different face “.

Siddhartha Mukherjee.

The Emperor of All Maladies, A Biography of Cancer, Winner of The Pulitzer Prize

Current trends in Breast Cancer in Ireland 1994-2013

According to the most recent trend reports published by the National Cancer Registry of Ireland,  1 in 10 women may develop breast cancer before the age of 75.

Breast cancer is the most common cancer with 2,883 cases diagnosed each year on average during 2011-2013. From 1994 to 2013 the Registry reports an increase of 1.5% in the numbers of women diagnosed with breast cancer but a decrease of 2% in the number of women dying from their disease. The 5 year survival rate in Ireland is now at 82%.

The trends for increasing survival are due in part to improvement in screening (increased public awareness and BreastCheck which was instituted in 2000) and improvements in treatment.

Treatment may be a combination of chemotherapy, surgery, radiotherapy, hormone therapy and/or immunotherapy.

85% of patients have surgery (and due to screening and early detection) there is a strong trend towards greater use of breast-conserving surgery (BCS) i.e. lumpectomy and radiotherapy. Compared with mastectomy (removal of the breast), lumpectomy allows faster recovery without the need for breast reconstruction. Lumpectomy now accounts for about two thirds of all surgical treatments for breast cancer.

The proportions of patients receiving radiotherapy have increased from 62% in 1999-2003 to 69% in 2009-2013, and hormone therapy from 49% to 55% over the same period.

HER2+ (positive) tumours are more aggressive (i.e. grow faster). Most breast cancers are now tested for HER2 status, and a high proportion of HER2+ cases received the monoclonal antibody trastuzumab (Herceptin), which reduces the risk of recurrence and death.  About 15% Irish cases diagnosed during 2011-2013 were HER2+ and, of these, 65% received trastuzumab (Herceptin).

The National Cancer Registry Ireland  http://www.ncri.ie


Usually breast cancer is slow growing and can spread microscopically for many years before it is detected. When a suspicious abnormal lump or thickening is detected on mammogram either a fine needle aspiration or excisional biopsy will be performed to confirm the diagnosis and facilitate appropriate surgical planning.


The Pathologist reports the stage (or burden) of the disease to the medical oncologist, the breast and reconstruction surgeons and radiation oncologist to help determine the patient’s course of treatment. The stage is typically divided at diagnosis into early (stage 1 and 2), locally advanced (stage 3) or metastatic categories (stage 4).

Including stage 0 there are 5 stages of breast cancer. The stage is determined by the size of the tumor, how many lymph nodes are involved and whether or not there are metastatic lesions.

There are 2 formal staging systems used. The TNM staging system illustrates key pathology information where T = Tumor size, N = Number of positive lymph nodes, M = Metastasis.

Stage 0 is used to describe non-invasive breast cancers, such as DCIS (ductal carcinoma in situ). In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or getting through to or invading neighboring normal tissue.

Stage 1 – T < 2cm; N = 0; M = 0

Stage 2 – T > 2cm but < 5cm; N = at least 1 node +ive; M = 0

Stage 3 – T > 5cm: N = some: M = 0 or T = some; N = high #;

M = 0;

Stage 4 – T = any size: N= any number; M = 1 metastatic disease is present in bone, liver, lung and/or in the brain.

Types of Breast Cancer

Non-invasive breast cancers

Examples of non-invasive cancers of the breast are Lobular and Ductal Carcinoma in Situ (LCIS and DCIS). LCIS is not believed to be a precursor of invasive disease whereas DCIS is an established precursor of invasive disease. DCIS is treated with BCS (breast conserving surgery “lumpectomy”) or mastectomy and radiotherapy to reduce the risk of recurrence.  Evaluation of the axilla may be but is generally not performed and 5 years of Tamoxifan may also be considered.

Invasive Breast Cancers

Lobular and Ductal carcinomas that have invaded the surrounding stroma and do have the capacity to metastasis – are referred to as invasive cancers. Approximately 75% of our patients are ductal carcinomas.

Less Common Breast Cancers

Paget’s disease of the nipple, inflammatory breast cancer, male breast cancer, invasive lobular carcinoma, medullary and tubular carcinomas and recurrent and metastatic breast cancer.

Key Breast Cancer Tests


A mammogram is a safe and generally accurate X-ray of the breast. Mammograms are the most useful test doctors have to screen, diagnose, evaluate, and monitor breast cancer. In the USA women at average risk of being diagnosed, screening mammograms begin at age 40. Higher risk women determine their screening schedule  in close consultation with their doctor.

Breast Ultrasound

Ultrasound is used to complement mammography to find out if an abnormality is solid (e.g. a tumor or fibroid) or fluid-filled (e.g. a cyst). In young women, mammograms alone can be difficult to interpret because their breasts tend to be dense and full of milk glands. Older women’s breasts tend to be more fatty and are easier to evaluate.

Genomic Tests

When there is a breast cancer diagnosis the Oncotype DX genomic test score is helpful with both prognosis (risk of recurrence) and predicting the benefits of having chemotherapy and radiation in both early stage breast cancer and in DCIS.


Oncoytpe Recurrence Scores For Early-Stage Estrogen Positive Breast Cancer

  • Scores lower than 18 = a low risk of recurrence + smaller benefit from chemotherapy
  • Scores of 18 up to and including 30 = an intermediate risk of recurrence + its unclear if the benefits outweigh the risks of chemotherapy side effects.
  • Scores greater than or equal to 31 = a high risk of recurrence + the benefits are greater than the risks of chemotherapy side effects.

The Oncotype DX scores for DCIS

Recurrence Score lower than 39 = low risk of DCIS recurrence + benefits are smaller than the risks of radition side effects.

Recurrence Score between 39 and 54 = an intermediate risk of DCIS recurrence + it’s not clear if the benefits outweigh the risks of radiation side effects.

Recurrence Score greater than 54 = a high risk of recurrence + , the benefits are greater than the risks of radiation side effects.

PET Scan.

Positron Emission Tomography, can detect areas of cancer by obtaining images of the cancer cells metabolizing radioactive sugar.

FISH Test and ImmunoHistoChemistry or IHC Test. 

These tests detect HER2 genes which stimulate the growth of breast cancer cells and will indicate if the breast cancer is “positive” or “negative” for HER2. Fish = Fluorescence In Situ Hybridization. HER2 is treated with Herceptin, Tykerb and Perjeta.


  1. CANCER REHABILITATION, Principals and Practice, Michael D Stubblefield and Michael W. O’Dell 2009 Pgs 181 – 193 Evaluation and treatment of breast cancer; Heather L. McArthur and Clifford A. Hudis, www.demosmedpub.com
  2. The Emperor of All Maladies, A Biography of Cancer, Siddhartha Mukherjee 2010, pgs 573 – end. Winner of the Pulitzer Prize. Ebook edition   www.SimonandSchuster.com
  3. The National Cancer Registry of Ireland. http://www.ncri.ie/publications/cancer-trends-and-projections/cancer-trends-29-breast-cancer
  4. http://www.genomichealth.com/ – Oncotype DX testing
  5. https://www.cancer.ie/ The Irish cancer society
  6. www.breastcancer.org
  7. www.cancer.ca Canadian Cancer Society
  8. www.cancer.org/ American Cancer Society

Breast Cancer Physio

Breast Cancer Rehabilitation For Physiotherapists

Updated October 2016. Written by Siobhan O’ Reilly Bracken MISCP PT MPA MSc CLT. Email questions and comments to Siobhan@theoreillycentre.ie

What has Physio to do with breast cancer?

What has physiotherapy to do with breast cancer?

Physiotherapists work closely with the patient’s oncology team and GPs to address the acute and chronic side effects of surgery, chemotherapy and radiation. Breast Cancer Rehabilitation aims to return each patient back to their pre diagnosis quality of life and beyond, towards living well.

Timely and effective Physiotherapy reduces the traumatic effects of the patient’s breast cancer experience. The skilled Physiotherapist may address pain, restriction, swelling, weakness and functional difficulties in a structured and professional manner. This care instills confidence and optimism and empowers patients to participate in their recovery and future well being, right from the beginning.

Breast cancer sometimes occurs later in life when a person may also have a significant co-morbidity. Physiotherapists are trained to safely address the common co-morbidities including, previous cancers, shoulder and spinal disorders, cardiac and lung pathology, diabetes, bone and joint pathology and neurological pathology affecting co-ordination, balance and endurance.

Cancer treatment is systemic and so affects the whole body not just the location of the tumor. Treatment side effects are therefore also whole body. Physiotherapists recognize that patients may have needs beyond their remit and often will refer patients to other members of the multi-disciplinary team, for example, for pain management, nutritional support and /or psychosexual counseling etc.

Specifically, Physio addresses:

• Pain and decreased shoulder flexion
• Cording and axillary web syndrome
• Adherent scarring, mastectomy, surgical drain and reconstruction scars
• Slow healing surgical wounds e.g. at the flap donor sites.
• Tissue stiffness after radiation therapy.
• Intercostobrachial neuralgia.
• CIPN neuropathies
• Bone density, joint pain and arthralgia.
• Capsular contractures after implant reconstruction
• Donor site rehab after reconstruction
• Cancer related fatigue
• Guidance with weigh lifting, aerobic and endurance training
• Prevention and management secondary lymphedema
• Cellulitis prevention, early ID and treatment.
• Education
• Meticulous skin care
• Self-manual lymph drainage (SMLD),
• Self-wrapping
• Compression sleeves when exercising and flying.
• Use of Antihistamine and antibacterial creams and antibiotics.

Exercise is medicine and Physios prescription is > 35 minutes daily

Our wellness experts all agree and recommend we all do more than 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise to enjoy the benefits of exercise – which includes the reduced risk of many diseases.

Daily walking, aqua therapy, biking, cross trainer, tennis, basketball, skiing to name a few examples, helps breast cancer survivors achieve lean muscle mass and optimal body weight, which is also co-related with less cancer recurrence.

Physios can facilitate this by researching and recommending suitable groups in their patient’s neighbourhood. Research shows that the more fun and high quality it is, the more likely a person is to experience positive results and to commit to it longterm. One of our tasks as Physios is to remove as many barriers as we can to help survivors of all ages and income levels to suceed in integrating exercise into their everyday routine so they can stay well and enjoy their lives.

Please send your questions and comments to Siobhan@theoreillycentre.ie

Nordic Walking Taking World by Storm

Nordic Walking Is Taking the World by Storm

Nordic Walking Versus Brisk Walking or Jogging

Aug 2018

Nordic Walking is taking the world by storm! The International Nordic Walking Federation (INWA) www.inwa-nordicwalking.com/ report having 20-member organisations with instructors from over 40 countries worldwide. In May of 2018, the INWA held a World Nordic Walking Day and in July held two World Cups, one in Quinghai, China and the other in Carnicava, Latvia. Events included the 5km, 10km and the 21km Nordic Walks for men and women. Winning times in the men’s 10km was 1:04:25 and in the men’s 21km was 1:57:45.

Technically, its closer to Nordic Skiing than hiking with poles. The hands are attached by straps to poles and as the arm plants the pole pushes backwards, engaging the upper body muscles and the body is propelled forward. Nordic Walking is a total body exercise as compared with regular walking or jogging.

Nordic Walking is typically performed 2-4 times a week for 10, 45, 90 minutes or longer, depending on the person’s disease, age, fitness level and athletic goals. Done correctly, Knobloch k et al in (2006) research shows a very low associated rate of injury. The most common injuries were strains to the ulnar collateral ligament (at the wrist on the pinkie side); the thumb (equivalent to skiers thumb); and the upper ankle.

If you would like to learn more, YouTube has numerous videos often produced by the NW Pole Companies e.g. EXEL. Also groups of Nordic Walkers are popping up in communities everywhere. To locate a Nordic Walking group near you, simply Google Nordic Walking with your location. Many Nordic Walking groups have trained instructors and offer workshops in the correct technique, organise days out, and even Nordic Walking holidays.

What does the research say about Nordic Walking?

The research on the health benefits linked to Nordic Walking is compelling. In 2013, M. Tschentscher et al, did a systematic review of all of the evidence including, sixteen randomised controlled studies (RTCs) with a total of 1062 patients and 11 observational studies with a total of 831 patients. The analysis showed that with regard to short- and long-term effects on resting heart rate, blood pressure, exercise capacity, maximal oxygen consumption and quality of life in a wide range of diseases, that Nordic Walking is superior to brisk walking without poles and in some endpoints to jogging.

Highlights of the systematic review: As compared with Walking and Jogging:  

1.      Nordic Walking is a safe form of endurance exercise for a wide variety of diseases.

The health benefits are greater for both healthy people and those with a wide variety of diseases including; breast cancer, obesity, chronic pain, heart disease, high blood pressure, breast cancer, lung disorders, Parkinson’s and depression disorders.

2.      Nordic Walking results in more weight loss.

For post-menopausal women as a cohort the results are particularly positive. In studies by Hager w et al (2009) and Figard-Faber H et al (2011), the health benefits after 12 weeks of Nordic Walking (40 minutes four times a week) included decreases in: BMI, total fat mass, low density lipoproteins, triglycerides and waist circumference.

3.      Nordic Walking generates more MET.

In Ainsworth’s (2000) compendium of physical activities: an update of activity codes and MET intensities, Nordic Walking generates up to 6.3-7.7 MET at brisk paces whereas brisk walking only reaches 3.3-5.0 MET. The cardio and respiratory response is increased by adding in the upper body muscles. Schiffer T, et al study in (2006) showed that NW up to a pace of 8.5km/hour, leads to a similar or higher values of VO2 and heart rate than jogging. Nordic Walking MET intensity of 6.3-7.7 closes the gap between brisk walking (3.3-5.0) and jogging and so offers people an excellent other choice for daily endurance exercise training.

4.      Nordic Walking improves shoulder mobility and decreases pain in Breast Cancer.

Bicego D et al (2009) and Irwin, M et al (2011) studies showed that regular physical activity positively affects exercise tolerance and quality of life in breast cancer patients. Leibbrand et al, (2010) study showed that Nordic Walking after Breast Cancer, additionally improves shoulder mobility and reduces sensitivity to pain in the upper body, without worsening lymphedema and can be recommended for breast cancer patients to increase their activity index.

5.      Nordic Walking reduces neck pain, low back and leg pain.

Henkel et al, (2008), study showed that after 8 to 12 weeks of Nordic Walking twice a week for 45 minutes, people complaining of different kinds of pain including neck pain, lower back pain and leg pain reduced their pain and the amount of pain medication they were using.

6.      Nordic Walking showed greater improvements in early cardiac rehab

A Randomised Controlled Trial (RCT) by Kocur et al, (2009) of patients in early, short-term inpatient cardiac rehab after an acute coronary syndrome, showed that the Nordic Walking group increased their lower body endurance and dynamic balance.

7.      Nordic Walking reduces depression and lifts mood.

Studies by Sturm J et al in (2012) and Knubben K et al in (2007) showed that “regular, moderate endurance exercise training is used therapeutically for moderate to severe depressive disorders, and has been shown to improve patients’ mood”. A study of 24 weeks of Nordic Walking by, Suija K et al in (2009) showed trends towards improvement in depression scores and quality of life.

Summary: Sedentary lifestyle predisposes all of us to diseases and conditions such as neck and low back pain, shoulder pain, hip, knee and foot pain, diabetes mellitus, weight gain, high blood pressure, coronary artery disease and depression. Lymphedema can cause a person to become sedentary and so increases risks of these sedentary lifestyle diseases. Also, some forms of endurance exercise training are associated with complications and injuries. For example, brisk walking with a vigorous arm swing can propel swelling into the hands and fingers and jogging can aggravate existing spinal, hip, knee and foot pain. Water based exercise is already recommended for a wide range of conditions and diseases including lymphedema. Buoyancy can be used either to assist or resist movement and hydrostatic pressure exerts a protective compressive force on the lymphedema limb.

The research is now also showing that Nordic Walking is safe and has a low risk of associated injury. For the same amount of time spent walking or jogging Nordic Walking uses more muscles and generates more MET. This safe, time efficient and effective form of endurance exercise training is better than brisk walking and jogging. Nordic Walking offers people with a broad range of diseases another choice of endurance exercise training. The Health Benefits include improvements in; BMI, resting heart rate, blood pressure, exercise capacity, maximal oxygen consumption (i.e. fitness) and quality of life.

The researchers conclude that, Nordic Walking can therefore be safely recommended to both healthy people who wish to prevent diseases related to a sedentary life style and to people with a wide variety of conditions and disease who wish to prevent secondary complications.

Lymphedema Precautions and Nordic Walking:

People with primary and secondary lymphedema should first discuss their Nordic Walking plans and get clearance from their GP or Consultant before starting. As with all exercise take the following precautions:

·         Discuss your Nordic Walking (NW) goals with your GP/Consultant/Physio before you start. Get medical clearance for exercise intensity up to 6.3-7.7 MET.

·         Learn the correct NW technique and use correctly sized Nordic Poles.

·         Hydrate before you exercise

·         Donn/wear the recommended compression garment on your lymphedema limb.

·         Go out early in the morning before it gets too hot.

·         Wear a sun hat, carry water and wear appropriate shoes/boots.

·         Before and after NW scan the at risk lymphedema limb for changes in swelling as compared with the other limb and modify your exercise accordingly.

·         Warm up x 5 minutes.

·         Plan and progress your time slowly and steadily towards your goal, over the first 12 – 16 weeks giving your body the time it needs to develop the new heart and muscle fibres, blood and lymph vessels it needs to grow to meet the increased demands of regular endurance exercise training.

·         Cool down x 5 minutes stretch the calf muscles on a step x 3 times for 30 seconds. THE END

The Gold Standard Treatment for Lymphoedema

The Gold Standard Treatment

What is the “Gold Standard Treatment” for lymphoedema?

February 2018.

Complete Decongestive Therapy or CDT is the “gold standard treatment” for lymphoedema. CDT consists of two distinct phases. Phase 1 when the Certified Lymphoedema Therapist (CLT) reduces the size of the limb and improves the skin. Phase 2 is when the patient is able to do their own treatment well enough to maintain the reduction achieved in Phase 1 and incorporate it into their daily lives, for their lifetime.

What are the side-effects of CDT?

CDT is a both a safe and effective treatment.

What are the results and benefits of CDT?

  1. Less swelling in the swollen limb.
  2. Improved lymph drainage
  3. Improved skin condition
  4. Less pain, stiffness and easier movement.
  5. Less cellulitis episodes and antibiotic use.
  6. Independence in activities of daily living (ADLs)
  7. Ability to participate in age appropriate activities
  8. Improved well-being and quality of life.

What exactly is CDT?

There are several components in both Phases 1 and in Phase 2 of CDT that together form the “gold standard” treatment to yield the desired results over the long term.

Components of Phase 1:

  1. Manual lymph drainage or MLD
  2. Multi-layer, short-stretch bandaging.
  3. Drainage exercises
  4. Meticulous skin and nail care.
  5. Compression garments
  6. Patient education in self-care.

Why is Phase I called the “intensive” phase?

Optimally, a lymphoedema limb may be bandaged daily for five days of the week for up to 2-8 weeks. This means daily therapy and daily bandaging for several weeks without interruption and so the label “intensive”. Patients may need both psychological and logistical support to get through the phase especially when it’s their first time. For example, a patient may still be recovering from their cancer diagnosis and treatment and must now cope with their new lymphoedema diagnosis. Supportive family and employers are also key as the patient needs time off from their other responsibilities. Others may need logistical support with transportation and activities of daily living (ADLs) e.g. food shopping, child care, house work etc.

Why is daily CDT optimal?

With each bandaging, the excess fluid moves up out of the limb to the regional lymph nodes at the pelvis or the armpit reducing the size of the limb. The bandages loosen as the limb shrinks. Daily re-bandaging will keep a consistent gentle pressure on the lymphatic vessels, maintaining the flow up and out of the limb. Ultimately, daily bandaging helps the patient reach their plateau point sooner and reduces their length of time in bandages.

Are there specialised INPATIENT lymphoedema centres within the EU?.

Yes, patients who cannot access the standard of care locally, may decide to go to the specialised inpatient centres in the EU for phase 1 of their CDT. Before they do go, it is recommended that the referring consultant, request the Klinic, send the patient home with a discharge summary in English and that the patient has a Certified Lymphoedema Therapist lined up to support them through Phase 2 and to monitor their progress. For information on availability and cost see:

How many days and weeks does Phase 1 take and when does treatment stop?

The patient wears the multilayer bandages day and night. After waking each morning they remove their bandages at home, shower, moisturise their skin, have breakfast and return to the clinic for their next treatment. Treatment includes, MLD, drainage exercising, education and re-bandaging. It’s repeated daily until the changes in limb size plateau. During these sessions the patient may be prepared and educated in self-management during Phase 2.

Once the reduction is complete the limb is measured for 2 sets of compression garments (so they can wash one and wear one). Custom made flat knit garments are an excellent choice and will need to be replaced every 4-6 months when the latex no longer provides the correct amount of compression to maintain the reduction.

What skills can patients learn for Phase 2

  1. Self-Manual Lymph Drainage (S-MLD).
  2. Lymphatic exercises e.g. (a) at home (b) in the pool
  3. Meticulous skin and nail care
  4. Compression therapy e.g. (a) Self-bandaging (b) Compression garments (c) Garments with Velcro (d) Pneumatic pumps.

Is medical monitoring useful and how often should a patient be monitored?

As with all chronic conditions, patient’s long term success will benefit from monitoring by their medical team and therapists to ensure that they have the support and advise they need. For example, compression garments and equipment suffer from wear and tear and need to be routinely checked for safe and effective use. Patient’s themselves change over the years and their self-care skills may need to be updated and modified so they remain appropriate. The medical team will monitor changes in the patient over time to guide their clinical decision making and recommendations, for example, they may monitor:

(a) Resting respiratory and heart rates, blood pressure and body temperature.

(b) Limb size or limb volume.

(c) Skin and nail condition.

(d) Body weight and or Body Mass Index (BMI).

(e) Pain intensity and location.

(f) Range of motion (ROM) of the affected upper or lower limb joints.

(g) Manual muscle test (MMT) of the affected upper or lower limb.

(h) Functional capacity testing to assess independence in Activities of Daily Living.

(i) Psychological screen to asses mental health status.

If you have comments or questions please contact Siobhan at oreillyphysio@gamil.com

Lymphoedema loves Aquatherapy

Swimming and Aqua-therapy

 Water Based Exercises For Your Leg Lymphoedema.

Aug 2017

If “exercise is medicine” then exercise in water may be “good medicine” for lymphoedema. Walking, cycling, dancing, lifting weights, yoga, Pilates etc are all wonderful for you, but if you like water and you have lymphoedema, consider the following special characteristics of water based exercise.

  • When you exercise in a pool or in the sea, the pressure water exerts on your body (hydrostatic pressure) is comparable to the pressure exerted by most compression garments, so you do not have to wear your compression garments.
  • The buoyancy you experience in water lifts your body weight off stiff or painful low backs, hips and knees, giving you the comfort you need to move in all directions, making it a total body exercise.
  • The resistance you experience as you move against the water makes your muscles and your lungs work. They pump and propel your lymph fluid through the lymph system to the nodes for filtering, keeping you healthy.
  • People with lymphoedema who use water for exercise, report their lymphedema limb “feels softer” immediately afterwards. This softer lighter feeling both rewards and inspires them to return to the pool. Regular exercise is corelated with has many important health benefits.
  • There are pools galore in every county in Ireland and at an average cost of 7.50 Euro a session, they are excellent value. Pools open most days including weekends and holidays, rain, hail or snow. So while exercising 3 – 6 days a week is a big comitement it is achievable.
  • To locate and select a pool that suits your needs, visit www.swimireland.ie/ and click on “Get Swimming / Learn to swim / Find a pool”, and see their list of the 10 pools closest to you.
  • For those who also like exercising in the sea, they can plan snorkelling and scuba-diving trips with friends and family.

What is the best water temperatures:

Normal body temperature is 98.6°F (37°C). The ideal temperature for water based exercising for people with lymphoedema is 94°F (34°C) degrees or slightly cooler. This temperature feels comfortably warm, soothes nerve endings, relieves pain, relaxes tense muscles and softens fibrotic lymphoedema. Water temperatures above 94°F (34.4°C) degrees, should be avoided because heat may increase lymphoedema. Strenuous exercise may also generate too much heat and increase lymphoedema.

So, it is preferable to exercise in a relaxed moderate manner in water temperatures of 94°F (34°C) degrees or slightly less. When you are checking out the pools near you or planning a seaside holiday inquire about the water temperature, so it suits your needs.

Can everybody with lymphoedema exercise in water?

Each person is unique and factors like your general health, your age, your balance and agility plus the condition of your skin and nails will need to be reviewed with your doctor, before you get into a pool.

Also, pool surfaces can be slippery and require you have excellent balance and agility to walk safely from the locker to the pool. Some pools have disability access e.g. life guards, seated cubicles to change in, non-skid flooring, hoist chairs, steps and ladders and safety bars to hold onto. Discuss all of this with the pool staff when you are calling around or when you ‘go, look, see” to help you select the one that best meets your needs.

The length of a session of water based exercise.

As with all types of exercise, people with lymphoedema do best when they start gently and progress slowly and patiently. This slow and progressive approach is safest as it gives your body time to adapt physiologically and gives you time to get to know your body’s reaction. It is “best practice” to check your lymphoedema before and after exercise to see if it is less or more. Based on this reaction, you can decide how to progress your program. You may wish to start with 10-15 minute sessions for example, working up, over several weeks to 35 – 45 minute sessions and then 55 minute sessions. As with all new activities, if you have any health and safety concerns, discuss with your doctor before you start.

Examples of water based exercises for leg lymphoedema

Introduction: Each session includes a 5-minute warm up, a 5-exercise circuit, followed by a 5-minute cool down. The program is progressed over the weeks by increasing the number of circuits. 

Examples of 5 minutes warm ups:

  • Stand chest high in water. Using safety bars as needed, breath in and out deeply 3 – 5 times, roll your shoulders back and down 3-5 times, stretch the sides of your neck by gently bringing your right ear to the right shoulder then the left ear to the left shoulder 3 – 5 times each side. Relax your mind and body and move gently and rhythmically to warm up and loosen up the spine, shoulders, hips and knees, wrists and ankles. Feel the ball of your foot as it lifts you forward with each step.
  • Walk slowly and calmly back and forth across the pool, go forwards, then backwards and then sideways. Do one or two laps on your tip toes and then on your heels.

Examples of leg circuits:

  • Squat down and gently jump up and repeat 3-5 times
  • Lunge on the right and then alternate to the left 3 – 5 times
  • Jumping jacks with the arms out for balance 3 – 5 times
  • March in place knees up 3 – 5 times
  • Power walk across the pool, moving arms and legs 3-5 laps
  • Rest for 30 – 90 seconds
  • To progress, repeat the entire circuit.

Examples of 5 minutes cool downs:

  • Stand chest high in water. Breath in and out deeply x 3-5 times, roll your shoulders back and down 3-5 times, stretch the sides of your neck by gently bringing your right ear to the right shoulder then the left ear to the left shoulder x 3 – 5 times each side. Relax your mind and body, move gently and rhythmically to cool down and loosen up the spine, shoulders, hips and knees, wrists and ankles. Feel the ball of your foot as it lifts you forward with each step.
  • Walk slowly and calmly back and forth across the pool, go forwards, then backwards and then sideways. Do one or two laps on your tip toes and then on your heels.

In summary: Water based exercises may be ideal for the person with lymphoedema. Fortunately, pools are in abundance in Ireland, are open most days of the week and all year round. Water based activities are whole body activities. People with lymphoedema can; move in comfort in water, train and condition their muscles, joints, hearts and lungs, develop a fit and strong body. For the adventurous, when on holiday with friends and family, strong and fit people with lymphoedema can enjoy sea water exercise and go snorkelling and scuba diving.